Transition from 4-valent HPV vaccine to 9-valent HPV vaccine

Human Papillomavirus (HPV) Vaccination: Transition from 4-valent HPV vaccine to 9-valent HPV vaccine Anagha Loharikar, MD Kevin Hansen June 3, 2015

No conflicts of interest to disclose.

Overview • HPV epidemiology & HPV-associated cancers • Prevention with Vaccination • Transition to 9-valent HPV vaccine • Vaccination coverage • Resources

HPV Epidemiology • In the US, almost everyone will be infected with HPV at some point in their lives • Estimated 79 million people in US currently infected • Estimated 14 million new infections each year • Highest rate of new HPV infections in 15-24 year olds • Estimated lifetime risk of acquiring HPV is 80% • Most people will never know they have been infected

HPV Epidemiology • Over 40 distinct types of HPV virus • 90% of infections are asymptomatic and resolve spontaneously within 2 years • Some types can lead to cancer or other benign diseases • 13 types of HPV are carcinogenic; HPV 16 and 18 cause 70% of cervical cancer • Of non-carcinogenic types, HPV 6 and 11 cause 90% of genital warts

HPV-Associated Cancer • Persistent HPV infection can cause CANCER

• 27,000 cases of cancer each year • Mostly cervical cancer in women • Mostly oropharyngeal cancer in men • 4,000 deaths each year

Cases of HPV-Attributable Cancer per year

HPV Prevention Vaccination is the BEST prevention

HPV Vaccines Currently Available Vaccine Product

HPV 2v Bivalent Cervarix

HPV 4v Quadrivalent Gardasil

HPV 9v 9-valent Gardasil 9

HPV Types

HPV 16 & 18

HPV 6, 11, 16 & 18

HPV 6, 11, 16, 18 &

31, 33, 45, 52, 58

Manufacturer

Glaxo Smith Kline

Merck

Merck

FDA Licensure

Females ages 9-25 years

Females & Males ages 9-26 years

Females ages 9-26 years Males ages 9-15 years

Dose Schedule

3 doses (0, 1, 6 months)



HPV Types Contributing to Cervical Cancer Worldwide



HPV Vaccination Recommendations • Routine vaccination at 11-12 years age – 3 doses (0, 2, 6 mo) • HPV 2v, 4v, or 9v for females • HPV 4v or 9v for males • ACIP has not stated a preference for any of the HPV vaccines currently available • May start at age 9 years • Vaccinate females up to age 26 years • Vaccinate males up to age 21 years (up to 26 years in highrisk) • Revaccination with 9v HPV to be discussed at next ACIP meeting

MMWR, CDC March 27, 2015.

HPV Vaccination Recommendations

MMWR, CDC March 27, 2015.

HPV Vaccination Why at 11-12 years age? • Better before sexual activity • Immune response better in younger patients • Already have an adolescent platform for vaccines

HPV Why at 11-12 years age? • Better before sexual activity • Immune response better in younger patients • Already have an adolescent platform for vaccines

Try saying: Your child needs 3 shots today – Tdap vaccine, HPV vaccine and Meningococcal vaccine. These will protect your child from tetanus, diphtheria, pertussis, cancers caused by HPV, and meningitis.

Transition to 9-valent HPV Vaccine • 9-valent HPV vaccine available for Chicago VFC providers on June 1, 2015 • Providers are required to use up current inventory of 2-valent and 4-valent HPV vaccine • CDPH recommends reducing orders of 2-valent and 4-valent HPV vaccine and using up current inventory before ordering 9valent HPV vaccine • 4-valent HPV vaccine will continue to be available on VFC ordering form.

Transition to 9-valent HPV Vaccine • Providers who choose to implement 9-valent HPV vaccine but still have 4-valent HPV in inventory, can consider using 4valent HPV to complete series or use for boys. • If providers do not know or do not have available the previously administered HPV vaccine product, any available product may be used to continue or complete the series.

HPV Vaccine Coverage

Source: National Cancer Institute, National Institute of Health, 2011.

Adolescent Vaccination Coverage United States, 2006-2013

MMWR 2014; 63(29);625-633.

Why is HPV Vaccine Different? HPV vaccine was sensationalized by popular media Parents think sexuality instead of cancer prevention Some clinicians aren’t giving strong recommendations Parents have questions that are seen as hesitation by some doctors • Phased girls-then-boys recommendations initially confusing to parents

• • • •

Parental Reasons to NOT Vaccinate for HPV

* Not mutually exclusive. ** Did not know much about HPV or HPV vaccine. National and State Vaccination Coverage Among Adolescents Aged 13–17 Years — United States, 2012 MMWR 2013; 62(34);685-693.

When Do Clinicians Recommend HPV Vaccine?

Allison et al. Academic Pediatrics, 2013.

What Can You Do? • Give a STRONG recommendation – How often do you get a chance to prevent cancer?

• Start conversation early and focus on cancer prevention – Vaccination given well before sexual experimentation begins – Better antibody response in preteens

• Offer a personal story – Own children/grandchildren/close friends’ children – HPV-related cancer case

• Welcome questions from parents, especially about safety – Remind parents that the HPV vaccine is safe and not associated with increased sexual activity

• Screen immunization status at every visit

Avoiding Missed Opportunities • HPV vaccine can safely be given at the same time as the other recommended adolescent vaccines • HPV vaccine can be provided during routine sports or camp physicals • Review immunization record even at sick/acute care visits • Encourage parents to keep accurate vaccination records and to review the immunization schedule

Provider Messaging: Focus on Cancer Prevention

Provider Messaging: Importance of Age Guidelines

Evidence-based Strategies to improve Vaccination Coverage • Reminder/recall system – Provider level (e.g., EMR prompts) – Parent/patient level (e.g., postcards, telephone calls, text messaging)

• Standing orders • Provider assessment and feedback – Assessment of vaccination coverage levels within the practice and discussion of strategies to improve vaccine delivery

• Utilizing immunization information systems www.thecommunityguide.org/vaccines/universally/index.html

Resources

www.cdc.gov/vaccines/who/teens/products/print-materials.html

www.cdc.gov/vaccines/who/teens/products/print-materials.html

Tips for Talking to Parents about HPV Vaccine Tools for your Practice

cdc.gov/vaccines/hpv-tipsheet

HPV • Parents should know: • HPV Vaccine is CANCER PREVENTION • Best to give at 11-12 years old • Important to give all 3 doses • Providers should know: • High rates of HPV infection • Make a STRONG recommendation • Continue to immunize even if patient is sexually-active • HPV vaccination is an important public health issue and it SAVES LIVES

@ChiPublicHealth [email protected]

/ChicagoPublicHealth www.CityofChicago.org/Health